Controversy about NSAIDs and heart health

by Marianna Rakovitsky, RPh

Recently there has been a lot of controversy  about the use of NSAIDs and heart health.

NSAIDs are medications for pain and inflammation. Many of them are sold over the counter and they are used by millions of people for various aches and pains as well as for more serious chronic conditions such as arthritis. Aspirin is technically an NSAID, but its effects on the heart are different from other drugs in this class.

Drugs such as ibuprofen and naproxen that are sold over the counter have been used by a large number of people for a long period of time. They are generally considered safe and are very effective for various types of pain. However the concern regarding the increased risk of bleeding, kidney damage and negative effects on cardiovascular system has always been associated with the use of NSAIDs.

Some examples of OTC (over the counter) NSAIDs:

  • Advil (ibuprofen)
  • Aleve (naproxen)
  • Motrin (ibuprofen)
  • Pamprin Maximum Strength All Day Relief (naproxen)
  • Midol Cramps and Body Aches (ibuprofen)

Some Examples of Prescription NSAIDs:

  • ibuprofen (Motrin)-available in many combination OTC and prescription products
  • naproxen (Anarox, Naprosyn, EC-Naprosyn, Naprelan)-available in many combination OTC and prescription products
  • ketoprofen
  • fenoprofen (Nalfon)
  • oxaprozin (Daypro)
  • indomethacin (Indocin)
  • diclofenac (Voltaren, Cataflam,  Voltaren gel, Solaraze gel, Flector patch)
  • etodolac (Lodine)
  • sulindac (Clinoril)
  • nabumetone (Relafen)
  • piroxicam (Feldene)
  • meloxicam (Mobic)
  • mefenamic acid (Ponstel)
  • meclofenamate

COX-2 inhibitor:

  • celecoxib (Celebrex)

In a June 10 article CNN reported the results of a large Danish study that found the connection between the use of ibuprofen-an active ingredient in Motrin and Advil, and diclofenac — an active ingredient in Voltaren and Cataflam, and increased risk of heart problems, stroke, and heart attacks. The effects of NSAIDs such as Motrin (iburofen) and Voltaren (diclofenac) on the blood pressure and heart has been known for a long time. Actually the increase risk of high blood pressure, stroke and heart attack is listed as a warning on most medications in this class.

When Vioxx (rofecoxib) a COX-2 inhibitor that is closely related to NSAIDs has been withdrawn from the market due to increased risk of heart attacks the concern for Celebrex (celecoxib)  as well as NSAIDs and their effects on the  heart health became a topic of a wide public discussion. The results of the new Danish study show that increase risk of cardiovascular problems may be caused by NSAIDS not only in people with known cardiovascular problems, but in a healthy population as well.

The Danish study has shown an association between increased risk of stroke and heart attacks with ibuprofen (Motrin) and diclofenac (Voltaren) , but not naproxen (Anaprox, Alieve, Naprosyn). Some previous research supports this conclusion. Generally naproxen is considered to have the least risk of cardiovascular complications. However there is one large study that questions that assumption. Alzheimer’s Disease Anti-Inflammatory Prevention Trial that was studying the effects of NSAIDs on Alzheimer’s prevention has shown an increase risk of cardiovascular events with Naproxen and no increase in risk with Celebrex . This study was stopped because of the concerns regarding the increased cardiovascular risk in patients treated with Celebrex that were emerging at the time of ADAPT study from other clinical trials as wells as the data that showed increased risk of cardiovascular events in patients treated with naproxen. There were several issues with the data collected for the study and the validity of the results of the study that has been stopped , so it may be difficult to interpret the results of this clinical trial. The recommendations of American Heart Association on the use of non-steroidal anti-inflammatory drugs regarding the risk of cardiovascular disease with NSAIDs include naproxen as well as other members of this class of drugs.

So where does this leaves millions of people who rely on these drugs for pain? As a general rule it is best to use the lowest effective dose of NSAID for the shortest period of time. If you are experiencing mild, self limiting condition that causes pain it is reasonable to try other approaches before taking NSAIDs. If you need to take an over the counter NSAID such as ibuprofen or naproxen for more than a couple of doses it is best to consult the doctor.

Always consult your doctor or a pharmacist about the use of any new medications if you have chronic medical conditions,  or take any other medications, supplements or herbs.

Marianna Rakovitsky is a pharmacist who blogs at the Healthialist Blog.

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  • Annie Stith

    Hey, there!

    I understand that there are cardiovascular risks involved with long-term use of NSAIDS. It was brought to my attention when the Bextra I was taking (the Cox-2 inhibitor nobody seems to mention) was taken off the market. Unfortunately, Celebrex doesn’t have the same beneficial effect for my pain from FM, CMP, OA, and DDD.

    Since going off of Bextra, I have taken a few different NSAIDS trying to find one that works for my pain. They are all on your list. I was finally able to settle on Diclofenac EC as a generic, which I take with Omeprazole because of the stomach upset it causes. Now you seem to be saying (or carefully avoiding saying) it may be just as dangerous for me as the Bextra.

    The problem is this: if NSAIDS have a detrimental effect even on those of us without cardiovascular risks (and no family history of such), where are we to turn for inflammatory pain? Is that what you’re saying?

    It’s already difficult to both get and deal with the stigma of opioids (I’m on a Fentanyl patch for baseline pain, and Oxycodone for breakthrough pain). They only mask pain, not reduce inlammation, and carry their own risks. But the worst of taking the Oxycodone is that I’m constantly dealing with the foregone conclusion that I’m an addict when I’m not. (At least, not beyond the “dependence” from using as directed.)

    Not being able to safely take NSAIDS is awful news for anyone dealing with moderate to severe chronic pain!

    Annie

  • Benjamin Atkinson

    NSAIDs: When is enough…enough?

    I’m wondering why so much time and money are spent in pursuit of more NSAIDs. I wonder if the resources could be put to better use.

    I also wonder why a physician would prescribe the newer NSAIDs. None have been shown to be more effective than aspirin. Stomach bleeds happen in a well-defined population, so those can be avoided. Is the patient demand for the new pill driving the prescribing behavior? Is it the DTC ads?

    Just curious. If anyone has any ideas, I’d appreciate reading them.

    In the meantime, the best summary I’ve found on the NSAID research is below:

    “The following is true about every NSAID
    that has been approved:

    1. Every approved NSAID has been shown to
    be more effective than placebo
    2. No approved NSAID has been shown to be
    less effective than aspirin
    3. No approved NSAID has been shown to be
    more effective than aspirin.
    4. No approved NSAID has been shown to be
    safer than aspirin.”
    (Hadler, N: Worried Sick, UNC Press, 2008)

    Ben